Commonwealth of Massachusetts Form CPF M 102: Campaign Finance Report Municipal Form Office of Campaign and Political Finance Fill in Reporting Period dates: Beginning Date: Ending Date: File with: City or Town Clerk or Election Commission Sep 9, 2016 Oct 31, 2016 Type of Report: (Check one) 8th day preceding preliminary 8th day preceding election 30 day after election year-end report dissolution E-mail: Candidate Full Name (if applicable) Office Sought and District Residential Address No CPA in Danvers Committee Name Keith Lucy Name of Committee Treasurer 7 Ashley Lane, Danvers, MA 01923 Committee Mailing Address E-mail: Phone # (optional): Phone # (optional): (978) 766-1274 SUMMARY BALANCE INFORMATION: Line 1: Ending Balance from previous report Line 2: Total receipts this period (page 3, line 11) Line 3: Subtotal (line 1 plus line 2) Line 4: Total expenditures this period (page 5, line 14) Line 5: Ending Balance (line 3 minus line 4) Line 6: Total in-kind contributions this period (page 6) Line 7: Total (all) outstanding liabilities (page 7) 0 3,376.63 3,376.63 2,852.4 524.23 0 Line 8: Name of bank(s) used: Salem Five Affidavit of Committee Treasurer: I certify that I have examined this report including attached schedules and it is, to the best of my knowledge and belief, a true and complete statement of all campaign finance activity, including all contributions, loans, receipts, expenditures, disbursements, in-kind contributions and liabilities for this reporting period and represents the campaign finance activity of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. 55. Signed under the penalties of perjury: (Treasurer's signature) Date: Oct 31, 2016 FOR CANDIDATE FILINGS ONLY: Affidavit of Candidate: (check 1 box only) Candidate with Committee and no activity independent of the committee I certify that I have examined this report including attached schedules and it is, to the best of my knowledge and belief, a true and complete statement of all campaign finance activity, of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. 55. I have not received any contributions, incurred any liabilities nor made any expenditures on my behalf during this reporting period. Candidate without Committee OR Candidate with independent activity filing separate report I certify that I have examined this report including attached schedules and it is, to the best of my knowledge and belief, a true and complete statement of all campaign finance activity, including contributions, loans, receipts, expenditures, disbursements, in-kind contributions and liabilities for this reporting period and represents the campaign finance activity of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. 55. Signed under the penalties of perjury: (Candidate's signature) Date:
SCHEDULE A: RECEIPTS M.G.L. c. 55 requires that the name and residential address be reported, in alphabetical order, for all receipts over $50 in a calendar year. Committees must keep detailed accounts and records of all receipts, but need only itemize those receipts over $50. In addition, the occupation and employer must be reported for all persons who contribute $ or more in a calendar year. (A "Schedule A: Receipts" attachment is available to complete, print and attach to this report, if additional pages are required to report all receipts. Please include your committee name and a page number on each page.) Date Received Name and Residential Address (alphabetical listing required) Occupation & Employer (for contributions of $ or more) Mark Zuberek 500 Retired Keith Lucy 456.63 Engineer, Teradyne Danversport Yacht Club 300 Oct 24, 2016 Ted Kontos 250 Self Employed Moore GMC Oct 4, 2016 LRC, LLC Sep 16, 2016 Bob Ryan Acculab Brothers Deli Donato Cobuzzi Fossa building The Trailer Shop Line 9: Total Receipts over $50 (or listed above) Line 10: Total Receipts $50 and under* (not listed above) 2,706.63 670 Line 11: TOTAL RECEIPTS IN THE PERIOD 3,376.63 f Enter on page 1, line 2 * If you have itemized receipts of $50 and under, include them in line 9. Line 10 should include only those receipts not itemized above. Page 2
Date Received Name and Residential Address (alphabetical listing required) SCHEDULE A: RECEIPTS (continued) Occupation & Employer (for contributions of $ or more) Oct 17, 2016 Pam Bartlett Oct 21, 2016 Ken and Ellie Hersey Line 9: Total Receipts over $50 (or listed above) Line 10: Total Receipts $50 and under* (not listed above) Line 11: TOTAL RECEIPTS IN THE PERIOD f Enter on page 1, line 2 * If you have itemized receipts of $50 and under, include them in line 9. Line 10 should include only those receipts not itemized above. Page 3
SCHEDULE B: EXPENDITURES M.G.L. c. 55 requires committees to list, in alphabetical order, all expenditures over $50 in a reporting period. Committees must keep detailed accounts and records of all expenditures, but need only itemize those over $50. Expenditures $50 and under may be added together, from committee records, and reported on line 13. (A "Schedule B: Expenditures" attachment is available to complete, print and attach to this report, if additional pages are required to report all expenditures. Please include your committee name and a page number on each page.) Date Paid To Whom Paid (alphabetical listing) Address Purpose of Expenditure Ben Franklin Printing 114 Maple St, Danvers, MA Lawn Signs / Literature 1,540 Oct 20, 2016 Danvers Herald 75 Conant St, Danvers, MA Print ad / Web ad 745.31 Oct 26, 2016 Matt Williamson 12 Cheever St, Danvers, MA Catering 125 Facebook.com Advertising 90 Sep 29, 2016 BannersontheCheap.com Banner 75.63 Oct 26, 2016 Currans's Florist 15 Park St, Danvers, MA Flowers 63.75 Line 12: Total Expenditures over $50 (or listed above) Line 13: Total Expenditures $50 and under* (not listed above) 2,639.69 212.71 Enter on page 1, line 4 g Line 14: TOTAL EXPENDITURES IN THE PERIOD 2,852.4 * If you have itemized expenditures of $50 and under, include them in line 12. Line 13 should include only those expenditures not itemized above. Page 4
Date Paid To Whom Paid (alphabetical listing) SCHEDULE B: EXPENDITURES (continued) Address Purpose of Expenditure Line 12: Expenditures over $50 (or listed above) Line 13: Expenditures $50 and under* (not listed above) Enter on page 1, line 4 g Line 14: TOTAL EXPENDITURES IN THE PERIOD * If you have itemized expenditures of $50 and under, include them in line 12. Line 13 should include only those expenditures not itemized above. Page 5
SCHEDULE C: "IN-KIND" CONTRIBUTIONS Please itemize contributors who have made in-kind contributions of more than $50. In-kind contributions $50 and under may be added together from the committee's records and included in line 16 on page 1. Date Received From Whom Received* Residential Address Description of Contribution Value Oct 28, 2016 Ben Franklin printing 114 Maple St, Danvers, MA Lawn signs Line 15: In-Kind Contributions over $50 (or listed above) Enter on page 1, line 6 g Line 16: In-Kind Contributions $50 & under (not listed above) Line 17: TOTAL IN-KIND CONTRIBUTIONS * If an in-kind contribution is received from a person who contributes more than $50 in a calendar year, you must report the name and address of the contributor; in addition, if the contribution is $ or more, you must also report the contributor's occupation and employer. Page 6
SCHEDULE D: LIABILITIES M.G.L. c. 55 requires committees to report ALL liabilities which have been reported previously and are still outstanding, as well as those liabilities incurred during this reporting period. Date Incurred To Whom Due Address Purpose Enter on page 1, line 7 g Line 18: TOTAL OUTSTANDING LIABILITIES (ALL) Page 7